Provider Demographics
NPI:1659829562
Name:SPINE STOP PORTLAND, PLLC
Entity Type:Organization
Organization Name:SPINE STOP PORTLAND, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:G
Authorized Official - Last Name:WATKINS
Authorized Official - Suffix:II
Authorized Official - Credentials:DC
Authorized Official - Phone:270-237-3304
Mailing Address - Street 1:352 OLD GALLATIN RD
Mailing Address - Street 2:
Mailing Address - City:SCOTTSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42164-8666
Mailing Address - Country:US
Mailing Address - Phone:270-237-3304
Mailing Address - Fax:270-237-3305
Practice Address - Street 1:305 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:TN
Practice Address - Zip Code:37148-1413
Practice Address - Country:US
Practice Address - Phone:270-237-3304
Practice Address - Fax:270-237-3305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-20
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2848111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty